Pelvic Infection and Infertility

Frederick R. Jelovsek MD

Pelvic inflammatory disease is still a frequent cause of infertility. Most of the time this infection starts out as a sexually transmitted disease (STD) caused by gonorrhea or chlamydia infections of the cervix. The infection may be relatively asymptomatic or cause some cervical discharge. If the bacteria ascend into the uterus and faloppian tubes, the infection causes pain from an accumulation of pus in the tubes. Antibiotics given early may prevent damage, but the body's normal host defense mechanism is to contain the infection in a walled-off abscess. This abscess will eventually resolve one of two ways. Either naturally, or with the help of antibiotics, the abscess cavity becomes sterilized and the fluid eventually becomes cleared and the abscess goes away, or the abscess ruptures and the infection spreads further to possibly cause more abscesses.

An article by Livengood CH III: Tubo-ovarian abscess. Contemporary Ob/Gyn 1999;44:108-116 points out how such infection can become very severe and may even result in death if a large abscess ruptures. The article helps us to answer several questions.

How does pelvic inflammatory disease (PID) affect fertility?

Once pathogenic bacteria such as Neisseria gonorrhoeae or Chlamydia trachomatis gain access above the cervix to the uterus and tubes, the inside surfaces of the faloppian tubes are denuded of their skin (epithelial) lining if a woman's immune system or antibiotics do not stop the bacteria. White blood cells, bacteria and fluids form in the tube which usually tries to contain the infection by forming a closed space. If a tube is filled with pus it is called a pyosalpinx. Even if treated at that point, the denuded inside of the tube may cause sticking together of the walls of the tube so that there is a blockage of the tube(s) later to sperm and eggs. For normal pregnancy, the sperm and the egg meet in the tube where fertilization takes place. Even if the tubes are not blocked by agglutination from past infection, the lining of the normal tube has a ciliary wave motion that serves to move the fertilized ovum down to the uterus. When that lining has been destroyed, infertility may result because the fertilized ovum does not get to the uterus in time for implantation.

If the abscess opens or leaks from the end of the tube, the ovary may stick to the end of the tube and become the far wall of another, bigger abscess cavity. This then would be called a tubo-ovarian abscess. When this happens, fertility on the side it occurs is totally obliterated because the ovary itself and all its eggs are destroyed.

How often does a pelvic infection lead to abscess formation?

Approximately 5-10% of the time, women with pelvic inflammatory disease (PID) develop the most severe form which is a tubo-ovarian abscess (TOA). Women who get TOAs tend to be older in their 30's and 40's. They have severe pain and may have nausea, vomiting and abdominal distension.

Are there other causes of tubo-ovarian abscess formation other than sexually transmitted diseases (STDs)?

Yes. Tubo-ovarian abscesses can form after other situations:

following any pelvic surgery

uterine perforation at time of a D&C or any vaginal uterine procedure

bowel perforation from ruptured appendicitis

bowel perforation from ruptured diverticulitis

pelvic malignancy

Even if the abscess is due to causes other than STDs, the clinical course is the same.

How will the doctor know if an infection has progressed to an abscess?

On pelvic exam, the doctor can often feel an abscess swelling. If the abscess is acute, a woman usually has a fever and an elevated white blood count (WBC). If it is chronic, she may not. Ultrasound is the best imaging study to use to detect an abscess although sometimes a CAT scan is used. In general, if the abscess cavity is over 8 cm in size (over 3 inches) , it is likely that surgery will be needed to treat the abscess because antibiotic treatment alone is not very successful when the abscess is that large.

What is the treatment for a tubo-ovarian abscess?

Even though the initial infection is often started from an STD bacteria, the abscess cavities should always be considered as a mixed infection with multiple different bacteria, many from the bowel tract just due to transmigration across swollen, inflamed bowel wall involved near the abscess. Therefore broad spectrum antibiotics are needed as soon as a diagnosis is made, Usually this requires at least two or three different antibiotics. If the infection does not improve within 48-72 hours, some sort of surgical drainage is needed. That may be done under xray guidance from a vaginal needle drainage, a needle drainage through the skin of the abdomen or by laparoscopy. If those do not work, then exploratory surgery with removal of all of the infected tissues is needed.